Provider Demographics
NPI:1265632715
Name:WASCHAK, JOHN PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:WASCHAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 NE E ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2326
Mailing Address - Country:US
Mailing Address - Phone:541-476-8383
Mailing Address - Fax:541-470-0751
Practice Address - Street 1:560 NE E ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2326
Practice Address - Country:US
Practice Address - Phone:541-476-8383
Practice Address - Fax:541-470-0751
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD90971223X0400X, 1223P0221X
CA550331223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics